Tuesday, December 16, 2014

It's the classic nursing moment: after you've spent uncounted minutes putting a gorgeously neat, clean dressing on a wound, a doctor walks in, takes the dressing down, and wanders off without a word.

(Which makes me wonder about the nurses who reference this moment: are their doctors that unpredictable? I always catch mine in the morning and ask when they plan to round; it's easier to work in a dressing change after six neurosurgery residents have looked at it. Maybe they don't have easily-cowed residents.)

That, at the very least, prompts an eye-roll and the exhalation of breath through gritted teeth. That's the bottom of the nurse-exasperation scale: the top is the shouted "What the FUCK do you think you're doing??" Somewhere in the middle is the terse conversation, either with a doctor or a family member, in the hallway, with a candlestick and Colonel Mustard.

Y'know what? I no longer have those conversations. Or, rather, I do, but they're not nearly as terse.

I no longer sigh heavily when a patient has explosive diarrhea right after I've rolled out a new pad.

I no longer roll my eyes when I hear that Manglement has opened a new critical-care unit and hasn't hired anybody to staff it.

I no longer, in short, give a shit. And it's made me a much better nurse.

See, there are things worth getting upset about. If I have a post-aneurysm-clipping patient whose blood pressure won't stay down, even with all the drips I can throw at them, *that's* worth flipping out about. If I have an acute ischemic stroke patient whose pressures won't stay up, even with ditto, *that's* worth a phone call or two. If the pharmacy forgets to send the super-special tubing with that bag of potassium phosphate, then yeah, I'mma get on the line to them.

But the usual, boring, irritating stuff, like dressings hurled flang-dang all over the bed? Not worth giving a shit over.

Likewise, every single corner must not be exactly perfect on the top sheet when the patient's up in a chair. I'll have a chance to fix it once they get back in the bed. Every single label doesn't have to be printed out on the in-room label printer if doing so means my labs will be delayed by twenty minutes; I can always send 'em down with a plain, pre-printed label. I can, if necessary, deal with too many patients in one assignment, because I have learned how not to give a shit. I have, in short, learned to prioritize.

More than prioritization, though, the art of Not Giving a Shit has helped preserve my mental health. I have a colleague who is brilliant, talented, very-very-very smart--the sort of nurse who walks around with a halo of golden light because she is just. So. Good.

She loses sleep over minor stuff: whether or not somebody will get mad at her because she missed charting the KVO rate on an IV for three hours, or didn't match the P&P exactly when she ran hot salt on somebody. It affects her personal life, it sometimes comes close to paralyzing her professionally, and it makes her miserable. She needs to learn not to give a shit.

I would say to her: First, is the patient safe? If so, excellent. Is the patient comfortable? Even better. Is the patient clean, fed, and neat-looking? You get a gold star. Is the patient calm in their mind about what's going on? Then you can sleep easy.

The fact that you might not've checked blood return every two hours on an IV, instead letting it go to two-and-a-quarter or two-and-a-half hours, is not worth worrying about. You'd kept a weather eye on that IV, you knew it was good; fifteen or twenty minutes will not make the world catch fire. Five cc's an hour is not a huge deal.

My Not-Give-A-Shit list goes something like this, in order of Not-Givingest to Most-Givingest:

1. Emails from anybody with extensive lettering after his or her name. If it comes from the president of the university, it gets deleted right away.

2. Emails from management that go out to everybody. Those get deleted, usually, without being read. If it's important, they'll cover it in a staff meeting.

3. Emails from management that go out to my unit. I'll glance over them.

5. Saline locks that don't work on patients with multiple saline locks. I'll take them out and may or may not start a new one, provided that person has at least one other working IV.

6. KVO orders that don't conform to unit policy. I'll run your IV at 5cc/hour; I may or may not get around to rewriting the order that the doc placed for "KVO fluids." (In my head is the Grecian chorus of They Ought To Know How To Order It By Now.)

7. No orders for Tylenol when the docs have already ordered Norco. They're cool about me stepping a patient down.

9. OT or PT skiving off a patient who they feel is too much trouble. In truth, I only have one occupational therapist that I have to watch closely; he looks for reasons to shorten his patient list. Dude, "patient already up in chair" does not mean you don't have to see them. The PTs and OTs where I work are spectacular. Except for that one dude.

10. Not breathing. That will get me full-on, hair-on-fire, running down the hall, giving a shit.

And I will have time to care, because I have learned how not to, for lesser stuff.

13 comments:

It sounds somewhat like raising kids -- learn to pick your battles, stand your ground on what really matters. Every line of work has this, the stuff to really care about, and the stuff that will work itself out.

That might sound awful to JCAHO, or John Q. Public ~to those of us in the trenches, we know it means we know how to pick our battles. That we've figured out all angles, and where to take the ~ I hesitate to say "short-cuts" ~

This. So this. When my partner was in the ICU, actively circling the drain (thank God they figured out what was happening and stopped it, but at the time it was looking really bad), we had a nurse that pitched an absolute fit because another nurse, trying to be nice, had tidied up the room and put a clean towel on the table as a tablecloth of sorts, since we had several cups of cold water for bathing face/hands to try and make fevered body feel better and the cups dripped. This nurse was incensed that something like that was happening because 'it could be a vector for infection!!!!'. At that point, my partner was so septic that licking the floor would likely have caused no more infection. A clean towel keeping the table from becoming a big puddle was the last concern I had - and had this woman been clued in even a touch to your philosophy, she'd have just made a mental note to make sure the towel was taken away in a couple of hours, like I did.

Making yourself crazy over small pointless things is a great way to burn out.

Love it! I have been practicing Not Giving a Shit myself. As long as all the patients are present and alive at the end of my shift, then all is good. "Not my circus, not my monkeys" is my other mantra.

Agree! If the patient is alive and stable at the end of my shift I did a good job. I have worked with way too many nurses that focus on everything but the patient. Newer nurses are the worst!! but we all were there at one time!!

Also, seasoned physicians I miss so much after working in a teaching facility with idiot interns/residents.

One of my nurse friends, who's also a writer, posted this great quote by David Simon. He's the guy who created the shows Homicide: Life on the Street and The Wire; the former of those was based on a book of a similar name, after he spent a year as a reporter following around the Baltimore Homicide Department.

The long and the short of it is that he went back to Baltimore Homicide ten years later and found that the cops that were still cops were the ones who'd figured out not to take it personally, while the cops who'd quit or been fired - especially the ones who had run screaming from the profession - were the ones who took every insult, every slight, every bad Manglement decision, even every day they served meatloaf in the work cafeteria, to be a personal affront. It didn't matter who was a good cop and who was a bad one. The one thing that mattered was whether or not they had the ability to shrug it off.

Reading that changed my nursing career, and my life, for the better. It takes practice - sometimes daily practice, and i'm definitely not perfect at it. But it's been so much easier to deal with everything when i can keep myself at arm's length.

Dear "don't give a shit anymore", I read your blog randomly after researching blogging and typed in nursing blogs. I am currently a ADN and rolled in the RN to BSN program and will graduate in July, 2015. I wanted to see if there was any room in the blogging world to share my own opinions and experiences as an RN. I find that more and more nurses have the same attitude as you do these days. I feel that nurses don't feel respected or appreciated the way they deserve, I have a feeling that is why you just don't care anymore. It sounds to like deep down your feeling not appreciated, and that the "I don't give a shit' attitude is a cover. My advice to you is voice your opinion as often as you can when you are disrespected in order to invite change in the nursing field. I would also like to state its a little scary that you feel like you don't care about being a professional anymore. Healthcare reform is here. And nurses are asked to advance their degrees and start taking on more leadership roles. One way you could start helping is by standing up for yourself. I know there is a great person inside who truly cares.